Optimizing Donor Management in Lung Transplantation

ABSTRACT Lung transplantation (LT), the only curative therapy for end-stage lung disease, improves survival and quality of life. Scarcity of donor organs remains the predominant barrier towards wider application of LT, yet the lung utilization rate (LUR) from brain-dead donors (BDDs) is only 25%. Two predominant factors account for the low LUR: heterogeneity in assessment of organs, and uncertain impact of donor quality on long-term recipient outcomes. This leads LT programs to adopt a conservative approach, declining up to 30% of potentially acceptable lung donor offers. To address both these factors, our group developed and validated a risk score, which is highly predictive of lung utilization from BDDs (c-statistic 0.89). The lung donor (LUNDON) score is derived from a parsimonious model comprised of nine routinely collected co-variates, four of which (PaO2/FiO2 ratio, Chest X-ray, creatinine, bloodstream infection) are potentially modifiable via donor management. Moreover, the score predicts long-term survival, particularly in high acuity recipients. Our data demonstrate wide variations in LURs nationally (14-40%) indicating the urgent need for standardization of donor management and acceptance practices. In partnership with the Organ Procurement Transplant Network (OPTN), using implementation science to inform this study and leverage our findings from the ongoing work, we propose the following aims: Aim 1. To identify the determinants of implementing the LUNDON score for lung transplantation. We will employ a sequential mixed methods approach using the capacity, opportunity, and motivation (COM-B) and Theoretical Domains Framework to identify facilitators and barriers for implementing the LUNDON score. Aim 2. To evaluate the impact of the LUNDON score on donor management practices. Using SimUNet, a unique platform developed by OPTN, participants who manage lung donors will be recruited for a simulated study and provided hypothetical donor scenarios with or without knowledge of the LUNDON score. We hypothesize that knowledge of the LUNDON score will promote lung protective ventilation strategies. Aim 3. To evaluate the impact of the LUNDON score on lung utilization rates. We will conduct a simulated study via SimUNet, where LT clinicians who evaluate lung donor offers will be asked to assess clinically relevant, lung offers for hypothetical recipients with or without knowledge of the LUNDON score. We hypothesize that providing the LUNDON score will improve the LUR. Aim 4. To develop a toolkit for implementing the LUNDON score. Through an adapted premortem exercise, we will develop, refine and pilot two distinct toolkits to support the implementation of the LUNDON score at organ procurement organizations (OPOs) and LT centers, respectively. Impact: Our proposal, with strong support from the OPTN and OPOs, will establish an evidence-based approach for lung donor assessment and utilization.